Glenhaven Healthcare

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent and immediately report, within the required two-hour timeframe, an alleged abuse incident involving verbal and physical altercations between residents. On the morning of 6/5/2025, a resident with a history of aggressive behavior kicked another resident's wheelchair and engaged in a verbal altercation. Despite this incident being witnessed and reported internally, it was not reported to the appropriate external agencies as required by facility policy and state regulations. The Director of Nursing (DON) acknowledged that the incident was not reported because there was no physical injury, contrary to the policy that mandates reporting all alleged abuse regardless of injury. The resident involved in the altercations had a documented history of schizoaffective disorder, bipolar disorder, and anxiety, and was noted to lack capacity to make decisions. This resident had previously exhibited aggressive behavior, including hitting an LVN on 6/2/2025. Despite these prior incidents, the care plan did not include specific interventions for supervision or monitoring to address the resident's aggressive behavior. On 6/5/2025, after the initial altercation in the hallway, the same resident later struck another resident in the activity room during a BINGO game, again without having been placed on increased monitoring or supervision. Interviews with staff confirmed that the incidents were reported internally but not to the required external authorities within the mandated timeframe. Staff members, including the Activity Director, DON, and others, stated that the policy required immediate reporting of all alleged abuse, but this was not followed. The facility's own policy emphasized prevention, identification, and timely reporting of abuse, but these procedures were not adhered to, resulting in a failure to protect residents from further harm.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper infection prevention and control measures for a resident who tested positive for influenza and required droplet precautions. During an observation, it was noted that the bedside curtain for the resident was partially open, despite the presence of two other residents in the same room. A certified nurse assistant (CNA) was observed wearing only a simple face mask, and the curtain was reported to be stuck, which prevented it from being fully closed. The infection preventionist confirmed that guidelines required the curtain to be fully closed to maintain droplet precautions. The resident in question was admitted with medical diagnoses including Diabetes Mellitus and Chronic Kidney Disease and was cognitively intact. The resident tested positive for influenza, and Tamiflu was prescribed. The Director of Nursing acknowledged that no single room was available for the resident, but emphasized that the curtain should have been fully closed to prevent the spread of infection. The failure to close the curtain as required by guidelines increased the risk of influenza spreading to other residents and staff in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary care and interventions to prevent pressure injuries for a resident, leading to the development and worsening of pressure ulcers. The resident, who was admitted with conditions such as Parkinson's Disease, spondylosis, and dementia, was assessed to be at high risk for pressure injuries due to limited mobility and incontinence. Despite being identified as high risk, the resident was not consistently turned, repositioned, or kept clean and dry, resulting in the development of a Stage 2 pressure injury on the sacrococcyx, which progressed to Stage 3 and eventually Stage 4. The facility's care plan for the resident included interventions such as offloading, repositioning every two hours, and using a Low Air Loss mattress. However, these interventions were not effectively implemented or monitored. The Treatment Nurse admitted to relying on staff reports without daily follow-up, and the Director of Staff Development did not maintain logs or provide specific training to CNAs after the resident developed pressure injuries. The Director of Nursing acknowledged the lack of a system to ensure consistent repositioning and incontinence management, and there was a delay in notifying the wound consultant about the reopening of the pressure injury. The facility's policy on skin breakdown prevention and management was not adequately followed. The policy required daily skin inspections, frequent incontinence care, and specific care plans for each resident, but these measures were not consistently applied. The lack of documentation and communication among staff contributed to the resident's deteriorating condition, as evidenced by the progression of the pressure injury and the eventual need for hospital transfer due to complications.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly dispose of garbage and refuse, as observed during a survey. A metal dumpster was found with its lid open due to overflowing trash bags, and additional trash bags, boxes, and an old mattress were left on the ground in the garbage area. This situation was noted during an observation and interview with the Maintenance Supervisor, who acknowledged the responsibility of the housekeeping supervisor to ensure the trash bin was emptied and the area kept clean. The Dietary Service Supervisor also confirmed that the kitchen shared the same trash bin and emphasized the importance of maintaining cleanliness to prevent pest infestation. The Administrator was unaware of the overflowing trash and surrounding debris until the survey and acknowledged the potential for pest infestation and health risks. The housekeeping supervisor admitted responsibility for maintaining the cleanliness of the garbage area and planned to request additional trash pickups. The Director of Nursing also recognized the risk of infection from pests attracted by the overflowing trash. The facility's policy on garbage disposal, dated August 2017, mandates that garbage and refuse be collected and disposed of safely, and the area around the dumpster be kept free of debris.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accommodate the needs of three residents by not ensuring that their call lights were within reach, which is crucial for them to signal for assistance. Resident 9, who was admitted with dementia and blindness in the left eye, was observed with a call light tucked between the mattress and bed rail, making it inaccessible. The CNA confirmed that due to Resident 9's blindness and weakness, they would not be able to locate or use the call light. Resident 45, diagnosed with dementia and Parkinson's disease, was found with a call light placed at the top of the bed over the pillow, out of reach. The resident, who experienced tremors and was unable to lift their arms over their head, stated they did not know where the call light button was. The CNA acknowledged that the call light was not within reach and should be accessible to ensure residents can request help. Resident 1, with a history of COPD, anxiety disorder, and muscle weakness, was observed with a call light hanging on the right side of the bed, pointing towards the floor and unreachable. The LVN noted that Resident 1 could use a call light if it were reachable. The facility's policy, as stated by the DON, requires call lights to be within reach to meet residents' needs and ensure their safety, especially in emergencies. The facility's policy and procedure document also indicated that call lights should be placed within easy reach of residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its policy and procedure for food storage and professional standards for food service safety. During an observation and interview with the Dietary Service Supervisor (DSS), it was noted that 15 ham sandwiches were stored in a refrigerator with an expired use-by date. Additionally, two hotdog buns were found in a clear plastic bag without a label or use-by date, and six breaded fish were in an open plastic bag in the freezer with an expired use-by date. A pitcher of prune juice was also found in the refrigerator without a label or use-by date. The DSS acknowledged that foods should be labeled with a use-by date and that expired foods should be discarded immediately to prevent potential contamination and health risks to residents. The Director of Nurses (DON) confirmed the importance of labeling food with a current use-by date as per policy to ensure kitchen staff know when to discard items and prevent serving expired food to residents. The facility's policy titled "Food Storage Principle" emphasizes preserving food quality, labeling packages with expiration dates, and discarding foods that exceed their expiration date or have not been used within 48 hours of preparation. The Food Code 2022 also requires ready-to-eat, time/temperature control for safety food to be clearly marked with a date or day by which it should be consumed, sold, or discarded when held at a temperature of 5°C (41°F) or less for a maximum of 7 days.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its infection control policy and procedures, leading to a deficiency in preventing the spread of infection among residents. Specifically, the facility did not ensure that a Certified Nurse Assistant (CNA) practiced proper hand hygiene and wore appropriate personal protective equipment (PPE) such as gloves and gowns when entering a resident's room under contact precautions. This lapse was observed when CNA 6 entered Resident 5's room, who was on contact precautions due to a multi-drug-resistant organism (MDRO) infection, without wearing a gown or gloves and without performing hand hygiene before and after the visit. Resident 5, who was admitted with conditions including Chronic Obstructive Pulmonary Disease (COPD) and metabolic encephalopathy, required maximal assistance for activities of daily living and was unable to make decisions. Despite the presence of a contact precaution sign outside Resident 5's room, CNA 6 failed to adhere to the facility's infection control policies. This included not using alcohol-based hand rub or washing hands with soap and water after leaving Resident 5's room and before entering another resident's room, Resident 42, who also had enhanced barrier precautions in place. The facility's policies clearly outlined the need for staff to wear appropriate PPE and practice hand hygiene to prevent the spread of infections, which was not followed in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a certified nurse assistant (CNA) was seated while assisting a resident during mealtime, which compromised the resident's dignity. The incident involved a resident who was originally admitted to the facility in 2016 and readmitted in 2024, with diagnoses including dementia and hemiplegia. The resident was dependent on assistance for eating, oral hygiene, bathing, toilet hygiene, and transfers. During an observation, the CNA was seen standing over the resident while feeding her, rather than sitting at eye level as required by the facility's policy. The CNA acknowledged during an interview that she should have been seated to maintain the resident's dignity. The Director of Nursing confirmed that staff should not stand over residents while providing feeding assistance. The facility's policy on meal assistance, dated April 2018, specifies that residents who cannot feed themselves should be assisted with attention to safety, comfort, and dignity, explicitly stating that staff should not stand over residents during meals.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an advance directive and a Physician Orders for Life Sustaining Treatment (POLST) were accessible in the medical records of a resident. This deficiency was identified during a review of the resident's paper chart, which did not contain a copy of the advance directive and the original POLST. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), confirmed that it was the facility's practice and protocol to have these documents in the physical paper chart to guide care during emergencies. The absence of these documents in the chart was acknowledged by the staff, who emphasized the importance of having them readily available to prevent delays in care. The resident involved had a history of dementia, seizures, and urinary tract infections, and was assessed as having severely impaired cognitive skills, requiring significant assistance with daily activities. The facility's policy and procedure documents indicated that the advance directive and POLST should be filed in the resident's clinical record and be easily accessible. The Director of Nursing (DON) also confirmed the expectation that these documents be present in the resident's chart, highlighting the potential for delayed or negatively affected care if they were missing.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision for two residents who were at high risk for falls. Resident 4, who had a history of falls and was assessed as a high fall risk, was observed reaching for drinks on a bedside table without a floor mat next to the bed, contrary to the care plan. The Licensed Vocational Nurse (LVN) was unaware of the need for a floor mat, and the Director of Nursing (DON) confirmed that the care plan was not implemented, which could lead to major injury from a fall. Resident 23, also a high fall risk, experienced a fall in a room that was not his own, resulting in skin tears. The care plan for Resident 23 included frequent visual monitoring, but there was no documentation of such monitoring. Staff members, including the Treatment Nurse (TN), Registered Nurse (RN), and Certified Nurse Assistant (CNA), were unaware of who was responsible for monitoring Resident 23 or why he was in another room. The DON acknowledged the lack of documentation and monitoring, which was highlighted by the fact that a visitor, not staff, witnessed the fall. The facility's policies on comprehensive care planning and fall prevention were not followed, as interventions to manage risk factors and ensure increased supervision for high-risk residents were not implemented. The DON admitted that there was no policy for supervision, but stated that high fall risk residents should be supervised at least every hour. The lack of supervision and failure to implement care plan interventions for both residents had the potential to cause major injury from falls.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement appropriate alternative interventions before installing bilateral 1/4 siderails for a resident, which could lead to the risk of entrapment and physical injury. The resident, who was admitted and readmitted with conditions such as hypertensive heart disease, chronic kidney disease, heart failure, and muscle weakness, was found to have moderately impaired cognition and was dependent on assistance for mobility. Despite these conditions, the facility did not attempt alternative interventions before resorting to siderails. The resident's medical records indicated that the siderails were installed for bed mobility and to assist with getting in and out of bed. However, the facility's assessment and care plan did not reflect the use of alternative methods before the installation of siderails. The assessment noted the use of frequent monitoring, reminders to use call lights, and restorative care, but no additional alternative interventions were implemented. Furthermore, the resident's head, neck, and chest were not measured to assess the risk of entrapment. Interviews with the Director of Nursing (DON) revealed that the facility did not follow its policies and procedures for bedside rail assessment and management. The DON acknowledged that the immediate use of siderails without implementing appropriate interventions could cause entrapment. The facility's policy required the use of alternate methods and the least restrictive measures before installing siderails, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in care documentation. For one resident, the Infection Preventionist (IP) did not document wound care treatment provided on a specific date, as she was covering for the treatment nurse and forgot to record it in the Treatment Administration Record (TAR) and Progress Notes. This resident had a stage four pressure ulcer requiring specific treatment, and the lack of documentation could lead to inconsistencies in care. The Director of Nursing emphasized the importance of documenting wound care to ensure continuity and accuracy in treatment. For another resident, there was an error in documenting the discharge disposition. The discharge summary indicated the resident was discharged to an assisted living facility, while the Minimum Data Set (MDS) inaccurately recorded the discharge to a hospital. The MDS Nurse acknowledged the mistake and stated that the resident's discharge disposition should have been documented correctly. The facility's policy and procedure on documentation guidelines require accurate recording of resident events, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that resident bedrooms met the required minimum size of 80 square feet per resident in multiple occupancy rooms. Specifically, 12 out of 16 rooms were found to be below this standard during a review of the Client Accommodation Analysis form. The rooms in question included Rooms 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14, and 15, which were all measured to be less than the required square footage per resident. Despite this deficiency, interviews with residents and staff indicated that there were no reported issues with the space available for care, movement, or privacy. During the re-certification survey, it was observed that the rooms provided sufficient space for residents' freedom of movement and the necessary nursing care. Each resident had access to individual bedside tables and over-the-bed tables, and the rooms were equipped to handle necessary medical equipment without impacting care delivery. The facility had submitted a Room Waiver Request, indicating that the Administrator and Director of Nursing would monitor room capacity and ensure that the rooms did not exceed their allowed capacity.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate treatment and care for a resident, identified as Resident 1, who experienced a change in condition. On the night in question, Resident 1, who had a history of chronic obstructive pulmonary disease, respiratory failure, and generalized anxiety disorder, began experiencing chest pain and difficulty breathing. Despite the resident's request to be transferred to an acute hospital, the facility delayed the transfer for over four hours. The resident's emergency contact, who was also the medical power of attorney, requested the transfer, but the Licensed Vocational Nurse (LVN) on duty did not take immediate action. The LVN, who was new to the facility and from a nursing registry, was the only licensed nurse on duty during the shift. She was unaware of the facility's protocol for handling such situations and attempted to contact the Director of Nursing (DON) and the Administrator for guidance but received no response. The LVN assessed the resident and initially determined that there was no distress, but later, when the resident reported chest pain, she called 911, and the resident was eventually transferred to the hospital. The LVN did not document the situation using the facility's standard SBAR form, which is a professional standard of practice. The facility's policies and procedures, including those related to resident rights, change of condition, and discharge against medical advice, were not followed. The DON, who is responsible for 24-hour accountability, did not respond to the LVN's messages until after the resident had been transferred. The failure to promptly assess, recognize, and intervene in the resident's change of condition, as well as the lack of documentation and adherence to protocols, contributed to the deficiency in care provided to Resident 1.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a Licensed Vocational Nurse (LVN) from a Nursing Registry demonstrated the necessary competency to provide adequate care for a resident. The resident, who was admitted with chronic obstructive pulmonary disease, respiratory failure, and generalized anxiety disorder, experienced chest pain and difficulty breathing. Despite the resident's emergency contact requesting a transfer to the hospital, the LVN did not take immediate action, citing a lack of awareness of the facility's protocol and inability to reach the Director of Nursing (DON) or Administrator for guidance. The LVN, who was the only licensed nurse on duty, assessed the resident and determined there was no distress, despite the resident's complaints. The LVN attempted to have the resident sign an Against Medical Advice (AMA) form, which was refused. It was not until the resident reported chest pain again that the LVN called 911, resulting in a delayed transfer to the hospital. Interviews with the emergency contact and the resident confirmed the resident's distress and the LVN's inaction. Further investigation revealed that the LVN had not completed the facility's nursing competency checklist prior to working at the facility, and there was no documentation of such. The DON confirmed the absence of a policy and procedure for staffing competency and acknowledged that the LVN did not create an SBAR, which is a standard practice at the facility. This lack of competency assessment and documentation contributed to the deficiency in care provided to the resident.

Penalty

Inspection fine: $18,070

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with dementia and combative behavior was free from physical restraints, which were used for discipline or convenience. On one occasion, a Licensed Vocational Nurse (LVN) restrained the resident by crossing their arms across the chest and above the head, dragging them from their room to the Nursing Station. This action was taken when the resident exhibited mood swings, anxiety, and agitation, leading to physical injury, including redness and bruising on the resident's hand, and verbalized pain in both hands and shoulders. The facility did not implement the resident's care plan interventions for dementia and communication problems, which included establishing rapport, making eye contact, and using appropriate words and gestures. The Interdisciplinary Team (IDT) failed to develop a comprehensive care plan to address the resident's new behaviors, such as combativeness, punching, scratching, and kicking, which were observed on multiple occasions. The care plan was not updated to address the root cause of the resident's behavior symptoms, nor were specific interventions developed to manage the resident's agitation and combativeness. The facility's policy on Physical Restraint Management was not followed, as the LVN used physical restraints to prevent being hit, kicked, and spit on by the resident. This resulted in the resident's freedom of movement being restricted, causing physical and psychosocial harm. The facility's failure to address the resident's behavioral issues and implement appropriate care plan interventions led to the unnecessary use of physical restraints, placing the resident and others at risk for further harm.

Removal Plan

• The facility interviewed 30 interviewable residents and screened for any incidents of being physically restrained during care by the Social Services Designee and 12 non-interviewable residents received body check to determine any unexplained bruising or redness by licensed nurses and the DON.
• The facility started Training and Education headed by the Nurse Consultant Director of Staff Education and the DON, regarding abuse and physical restraints. The training on Managing Behavior and Care plan will be completed.
• The facility started ln-service training for staff nurses regarding updating comprehensive care plans for residents that exhibit combative behaviors to be completed and to include on the care plan not to use any type of restraints.
• The facility started an In-service training for staff and nurses on managing residents that exhibit combative behaviors. Staff from nursing department (Registered Nurse, LVN, Certified Nurse Assistants, Restorative Nurse Assistants) Dietary Department, Housekeeping, Maintenance and Department Managers (Social Service, Medical Records staff, Rehabilitation Department, Minimum Data Set, DON, DSD, IPN, Business Office Manager), have been trained and will continue training until all staff have attended.
• The facility conducted an In-service training for staff (RN, LVN, CNA, RNA, Housekeeping, Dietary Department, Maintenance and Department Managers) on what constitutes a physical restraint and its definition.
• The nurse consultant conducted an In-service to all RNs, LVNs, CNAs, and RNAs, Housekeeping, Maintenance staff, Dietary staff, and Department Managers regarding Behavior Management, Abuse and Physical Restraints.
• The SSD, DON and Activity Director will conduct interviews of alert residents to determine if they have been physically restrained during care at least daily for the next 3 days and weekly for two weeks and monthly thereafter.
• CNAs will continue to conduct body checks for all residents to identify any unexplained redness or bruising during showers and will be reported to the Charge nurse/Treatment nurse and/or to DON for further intervention and reporting.